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General NPI Number Information
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NPI Number | 1750754818
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Entity Type | Individual
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Provider Name | KHALID HASSAN MUTAWALLI D.D.S,M.S
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Gender | Male
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Dates
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Enumeration Date | 11/10/2015
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Last Update Date | 09/10/2016
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Provider Practice Location Address
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Address Line | 3625 COLLEGE AVE BX1822
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City | DAVIE
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State | FL
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Zip | 33314-7724
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Country | US
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Telephone | 202-560-3320
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Fax |
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Provider Business Mailing Address
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Address Line | 215 SE 8TH AVE APT#1640
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City | FORT LAUDERDALE
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State | FL
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Zip | 33301-3644
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Country | US
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Telephone | 202-560-3320
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | DN 20908
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License Number State | FL
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